Kapi Mana Multiples

PO Box 50781, Porirua 5420 KMM New Membership Application Form

The KMM Annual Membership Subscription is $40 (1 July – 30 June) Annual membership entitles you to club newsletters, a membership card (which can be used to get discounts at selected retailers), playgroups/support groups, clothing grabs, social gatherings, antenatal education (specific to multiple pregnancy and birth), equipment for hire and a network of like parents and families. Your Name: Partner’s Name:

Address: Contact Phone Numbers: Email Address: Expected Due Date: Expecting: Twins / Triplets / More

Already have children?: Yes/No Please give details below Multiples? Twins / Triplets / More

Other Children’s Names and Dates of Birth: First Name Surname Date of Birth Gender (M/F)

The club address list is only made available to club Committee Members. I agree to have my details included on the club address list. Yes / No I authorise the club to use photos taken at club events in our private, closed Facebook group Yes / No Why did you decide to join our Multiple Birth Club? (Please mark below) Friendship / Support / Education – pre and post natal / Social Events / Multiples Playgroup / Access to Equipment or Clothing / Other: (please specify)______

How did you initially find out about Kapi-Mana Multiple Birth Club: (please mark below) KMMBC Website / NZMBA Website / Lead Maternity Carer / Family or Friend / Antenatal Class / Plunket Nurse / Other: (please specify)______Are you interested in joining our committee? Yes / No Can you host an evening or weekend social event? Yes / No Would you be interested in contributing to our newsletter? Yes / No

Please return your completed membership form to The Secretary, KMMBC, PO Box 50781, Porirua 5420 or email this form to [email protected]. Payment by posted direct credit (preferred) or cheque: Internet Banking: Westpac A/C #03 0547 0892743 00 Date of Transaction:______Please include your surname and initials in the reference field so we can match forms with payment. Cheque Please make cheques out to Kapi-Mana Multiple Birth Club NB: If you feel you are unable to join our club due to financial reasons please contact the New Members Officer at [email protected]

Supporting families of multiples in our community www.kapimanamultiples.org.nz